Healthcare Provider Details

I. General information

NPI: 1013216373
Provider Name (Legal Business Name): KEITH THOMAS BANGART DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13660 N 94TH DR #F1
PEORIA AZ
85381-4836
US

IV. Provider business mailing address

13660 N 94TH DR #F1
PEORIA AZ
85381-4836
US

V. Phone/Fax

Practice location:
  • Phone: 623-974-0522
  • Fax: 623-933-5787
Mailing address:
  • Phone: 623-974-0522
  • Fax: 623-933-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0724
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: